Cuban health care as an exemplar

With class established as a major negative public health impact in nations with a vast disparity of wealth and lacking a national health program, we’ll turn to one example of a poor nation with a remarkable public health plan. It even includes full dental.

The Cuban health care system ignites intense political debate, with every fact questioned. Furious controversy surrounds the statistics reported by international organizations. But the fact remains that many public health professionals around the planet are impressed with Cuba’s remarkable ability to provide a level of care that rivals and sometimes exceeds that of the world’s richest nations. And the data clearly show that children of African heritage fare far better in Cuba than in the United States.

The public health mandate is enshrined in Article 49 of the national Constitution, which states:

Everyone has the right to health protection and care. The state guarantees this right.

by providing free hospital and medical care by means of the installation of the rural medical; service network, polyclinics, hospitals preventive and specialized treatment centres;

by providing free dental care;

by the health publicity campaigns, health education, regular medical examinations, general vaccinations, and other measures to prevent the outbreak of disease. All the population cooperates in these activities and plans through the social and mass organizations.

Why has Cuba been able to do so much with so little, and in the face of a U.S. economic embargo that denies the island access to much of the world’s best medical technology and medications?

Dr, Peter G. Bourne, a physician, public health expert, and scholar at Green Templeton College at Oxford, is one of leading experts on and a strong proponent of the Cuban public health system and a strong proponent of ending the U.S. embargo.
In a lecture at the University of Pittsburgh he describes the system which has made Cubans “among the healthiest people in the world.”

Universal access to care was the initial primary goal. It was matched with another vital element-the integration of treatment services with public health strategies. Physicians were not only responsible for delivering direct care but also for leading preventive programs in the catchment areas they served. Working with the “community health committees” they insured that no pregnant woman could go without antenatal care, that one hundred per cent of children were vaccinated against the basic childhood diseases, that the people in the community were regularly screened for breast and cervical cancer, as well as chronic diseases such as hypertension and diabetes whether or not they were symptomatic. The physicians and nurses in the polyclinics were also responsible, especially in rural areas, for environmental health issues such as insuring the quality of the water supply to which the community had access and the elimination of mosquitoes. The cost effectiveness of preventing rather than treating disease was thoroughly understood and animated the way physicians view their the responsibility. It is the philosophical and practical integration of service delivery and public health that is the real hallmark of the Cuban health system. . .

The result has been that Cubans, forty-five years on and no matter what their life circumstances, are among the healthiest people in the world.

In this brief clip he makes a strong argument for ending U.S. sanctions.

Rahima Dosani examined comparative mortality studies in the U.S., India and Cuba for an article last June in Global Pulse Journal, published by the American Medical Student Association . Her report merits quoting in depth:

Although the United States does spend a significantly larger portion of its gross domestic product on health care and while the United States does have a much higher gross national product compared to India, the argument that economic development is largely responsible for health improvements is obliterated when the Cuban health statistics are factored into the mix. Cuba spends only 6.3% of its gross domestic product on health expenditures compared to the 15.4% spent by the U.S., and has a much lower gross national product than the United States. Despite these disparities, as well as substantially lower per capita health expenditures in Cuba ($229) versus the United States ($6,069), Cuban health indicators are largely equal to those of the United States. Spiegel et al comments on the Cuban health paradox: “Cuba’s experience challenges the conventional assumption that generating wealth is the fundamental precondition for improving health.” Indeed, males between the ages of 15 and 60 have a higher chance of dying in the United States (137 per 1,000 members of the population), than in Cuba (128 per 1,000 members of the population). Females in this age range have roughly the same chance of dying in the US and Cuba (81/1,000 to 83/1,000), and the infant mortality rate for Cuba is the best out of all three countries (5 deaths per 1,000 births, compared to 7 in the U.S. and 56 in India). Life expectancy in years is almost identical for both males and females in the United States and in Cuba9. Cuba and India share very similar levels of per capita GNP ($3,649 in Cuba versus $3,460 in India), yet the health outcomes for Cuba are considerably better than India. The great similarity in health indicators between the United States and Cuba despite their vast differences in economic development point to another argument for underlying causes of health.

In 1961, the Cuban government published a report stating its views on development and health: “Medicine alone will not improve the overall health of the population. What will improve it is embedding medicine within a significant transformation of the socioeconomic structure to eliminate the problems of underdevelopment: the legacy of hunger, illiteracy, inadequate housing, discrimination, and the exploitation of labor.” Cuba has worked extremely hard to increase the percentage of its rural population with access to sanitation, which remains around 95%. This number is stunning given that Cuba is still a developing country, and is especially remarkable compared to India’s statistic of 22% of its rural population having access to sanitation. A rationing system of the food in Cuba also ensures an “equitable distribution of basic dietary needs.” Additionally, Cuba’s rate of primary school enrollment for boys and girls is 97% and 95% respectively, which tops even the United States’ primary school enrollment percentages. This has led to an adult literacy rate of 99.8%, exactly equal to that of the United States. One of the strongest adult health indicators is the level of education that one has, and there is a noticeable gradient relationship between the level of education one has and their mortality and morbidity throughout their life. Increasing education for women has done wonders for improving the infant and maternal mortality rates in Cuba and has empowered women to seek health care and employment on their own.

The Cuban commitment to equality in social services such as education, nutrition, and housing has had great impacts on the health of the Cuban people. Cubans have moved even a step beyond equity of health care services, and this equity has begun to produce equality of health states among different members of the population. There are dramatic differences between the Cuban health system and the United States health system. The largely private health-care system of the United States leads to many more out-of-pocket expenses than the public health care system in Cuba. Perhaps as a result, the number of bankruptcies due to medical reasons increased 23 fold between 1981 and 2001. These facts support the theory of reverse causation—that poor health can often cause a low socio-economic status in the U.S., in addition to the view that low socio-economic status can cause poor health.

More on the Cuban system as seen by health professionals may be found here and here.

The next post of the Cuban health system will examine, among other topics, the impacts of the U.S. embargo and the collapse of the Soviet Union.